Atlas of Emergency Neurosurgery - Ebook download as PDF File .pdf), Text File .txt) or read book online. Th is a t la s e d it e d b y Dr s. Ullm a n a n d Ra k s in. lavishly illustrated with numerous large, detailed, color photographs depicting key steps in the procedure, with the prose describing each step kept close on the . Get this from a library! Atlas of emergency neurosurgery. [Jamie S Ullman; P B Raksin; Jennifer Pryll;].
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It seems like everyone has a neurotrauma textbook these days. A relatively small subspecialty can only support so many textbooks without one. download the eBook Atlas of Emergency Neurosurgery by Jamie S. Ullman online from Australia's leading online eBook store. Download eBooks from Booktopia. Atlas of Emergency Neurosurgery. Jamie S. Ullman, MD, FAANS, FACS. Associate Professor, Department of Neurosurgery. Hofstra North Shore-LIJ School of.
Jamie S. Be the first to write a review. Share This eBook:. Add to Wishlist. Instant Download. Description eBook Details Click on the cover image above to read some pages of this book! Key Features: More than beautiful, full-color illustrations help clarify each procedure Contains the most current information on how to perform emergency neurosurgical procedures Concise presentation of procedures gives readers quick, easy access to key information This atlas is an ideal guide for neurosurgery residents who are participating in emergency procedures while on call and need to deal with operative trauma situations.
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Warner Jr. Th e pat ien t sh ould be given seizure prophylaxis at earliest opport un it y after arrival to th e h ospit al. In cases w ith kn ow n bet adin e or iodin e allergies. Th e presen ce of p olyt rau m a. The operative eld should be prepared using an iodine-based sterile prep solution.
Th e use of ch lorh exidin e is con t roversial. Th e in cision s are m arked an d. Tim m ons Introduction Preprocedure Considerations Rapid evacu at ion of ext ra-axial h em atom as after t rau m a can be a life-saving in ter ven t ion.
W h ile th ere is n o absolute cuto t im e after w h ich pat ien t s fare w orse. Eviden ce-based gu id elin es su p p or t th e u t ilizat ion of an t iconvu lsan ts for 7 days in pat ien t s follow ing t raum at ic brain injur y. Reverse Trendelenburg positioning m ay be used to provide elevation of the head to help reduce cerebral edem a.
Allowance for central venous catheters. Pressure points should be padded appropriately. Final draping should exclude the anesthesia setup. Foley catheters should always be placed and should be accessible to the anesthesia team. The eyes should be protected from corneal abrasion by placing ointm ent under each lid and taping the lids shut.
Pin xation may also be used. The head may be placed on a foam or gel doughnut to expedite positioning. An exit site for a subgaleal drain should be included in the area exposed by the sterile draping. ETT collar. The head should be positioned just at or slightly overhanging the end of the table and the sterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation by gravit y.
The patient whose neck has not yet been cleared can be positioned in the cervical collar by placing a bolster under the ipsilateral shoulder and the ipsilateral arm across the chest. The question mark or reverse question mark incision illustrated here is used commonly to access large traumatic extra-axial hematomas. When using a question m ark incision.
The temporalis m ay then be divided in parallel with the incision using Bovie cautery. A m argin of at least 1 cm should be used. Branches of the super cial and m iddle temporal arteries may be encountered and m ay be ligated and divided sharply. The scalp m ay be elevated o of the underlying bone and retracted out of the way. Scalp clips m ay be applied to the scalp edges to aid in hem ostasis. Prior to opening the scalp over the temporalis m uscle.
The musculocutaneous ap should be protected from strangulation by placing dry sponges counted behind the ap. Bipolar cautery m ay be used sparingly on scalp and m uscle vessels. A sponge soaked with irrigation infused with epinephrine m ay be placed on the undersurface of the galea and m uscle to aid in hemostasis. If possible. The explanted bone ap should be cleared of hem atom a and blood and placed in irrigation infused with antibiotics on the back table until ready to be replaced.
Excess wax is rem oved. A larger instrum ent. The high-speed drill attachment is converted to a cutting bit w ith a footplate and used to connect each pair of bur holes circumferentially. Center holes may be m ade later in the bone ap for epidural tack-up sutures. Venous epidural hem atom as sometim es require application of gel foam soaked in throm bin and gentle pressure. The hem atom a is often adherent to the bleeding vessel. This may be removed using irrigation and suction.
The dural edges may then be grasped w ith ne -toothed forceps. If the brain is signi cantly edem atous and the dura is taut. Dural vessels m ay be coagulated with the bipolar at the edges of the cut dura.
The dural ap or aps should be weighted with hem ostats in order to prevent shrinkage during the procedure as m uch as possible. The dural edges should be secured with braided nylon sutures. Well-form ed hematom as m ay be grasped with biopsy forceps and gently elevated from the brain surface while ushing the area with ample irrigation.
The site should be irrigated again to ensure no active bleeding prior to dural closure. A brain retractor blade m ay be used to gently depress the brain during this phase. If an active bleeding source is identi ed which is not always possible.
Gentle irrigation with sterile saline should be used and the entire perim eter of the dural exposure explored with adequate lighting to ensure that the hem atom a has been completely evacuated.
The source is often a cortical surface vein or artery. A central epidural tacking stitch may be brought out through tw o holes drilled in the bone ap. Over the Epidural tack-up sutures are placed through small drill holes placed around the perimeter of the craniotomy. The dura may be closed with simple running. Prior to placing the nal few sutures. For large dural defects not am enable to prim ary closure due to shrunken dura. Resorbable plates and screws are available for children.
These are generally m ade of titanium. The central epidural tacking stitch is secured. The drain is at tached to bulb suction. The galea is closed w ith interrupted. If ongoing coagu lopathy is obser ved. Invasive h em odyn am ic m on itoring arterial lin e. Th e auth or prefers to apply a st rip of n on adh eren t pet rolat um gauze over su t u res or st ap les to p reven t p u lling.
As the scalp closure proceeds. After du ral closu re. St rip s of dressing tape m ay be u sed to follow th e cur vat ure of th e h ead parallel to th e in cision for close adh eren ce.
Sterile salin e irrigat ion is ut ilized in th e in t radu ral space. Th e dressing is secured w ith st retchy dressing t ape. If th ere is sign i can t out p ut. Skin su t u res or st ap les are rem oved on or abou t p ostop erat ive day 10 to Tem poralis m uscle and fascia are reapproxim ated w ith 0-gauge braided absorbable suture.
Th e presen ce of d ocu m en ted seizu res m ay p rovide an in dicat ion to con t in u e th erapy beyon d th is w in dow. Extern al su t ure is requ ired on th e scalp. Th e dressing is rem oved an d th e w oun d is clean sed w ith w arm w ater an d m ild soap or sh am p oo after 24 h ou rs.
Th e skin m ay be closed w ith nylon or oth er n on braided sut ure. Pressor support m ay be n ecessar y to m ain tain adequate cran ial perfu sion pressu re d ep en ding on th e clin ical pict u re. Th e dressing is rem oved after 24 h ou rs. Sw an -Gan z cath eter m ay be in dicated to assist m an agem en t in crit ically ill pat ien t s. Th is base dressing.
Special Considerations Preoperat ive plan n ing is im port an t in th e m an agem en t of t raum at ic SDHs. Neurosurger y Gh ajar J. S16—24 4. References 1. Su rgical m an agem en t of acute epidural h em atom as. J Neurot raum a Bu llock MR. Man agem en t an d progn osis of severe t raum at ic brain injur y.
S7—S15 3. S83—86 J Neu rot raum a Plan n ing for p ossible decom p ressive cran iectom y m u st often be in corp orated in to th e p osit ion ing. Su rgical m an agem en t of acute subdural h em atom as. Clifton GL. Pat ien t s w h o are likely to require th e bon e ap to be left out in clude th ose w ith m idlin e sh ift ou t of p roport ion to th e th ickn ess of th e SDH. An t iseizu re p rop hylaxis.
Bu llock et al. Bu r h ole drain age is perform ed m ost com m on ly. If th e CSDH is large an d causes sign i can t m ass e ect.
Preprocedure Considerations Radiographic Imaging Figs. In addit ion to th ese su rgical tech n iques. W h ile adequate drain age can be ach ieved even in th e presen ce of a few su bdu ral m em bran es. Th is suggest s th e subdural h em atom a is su cien tly lique ed to perm it drain age via a ven t riculostom y cath eter. Man agem en t of CSDH t yp ically involves su rgical evacu at ion of th e clot an d placem en t of post surgical drains to preven t reaccum ulation of blood in th e subdural space.
The prevailing hypoth esis is th at m ost start as acute subdural bleeds th at t rigger a local in am m ator y respon se in th e surroun ding m en inges. A sm all am oun t of acute. The presence of an isodense. SDHs classically d e m on st rate a crescen t ic con gu rat ion. In am m at ion t riggers th e m igrat ion of broblast s. Th e Am erican Associat ion of Neurological Surgeons procedural survey rep or ted over In gen eral. These usually can be drained e ectively w ith a bedside catheter or suction evacuation procedure.
In part icular. Jonathan Rasouli. W hen th e radiograph ic appearan ce is favorable. Mort alit y st at ist ics var y am ong in st it u t ion s. Bur h ole drain age or cran iotom y sh ould be con sidered in th is set t ing.
X-ray is a poor diagn ost ic tool for CSDH. Hem oglobin even t u ally is broken dow n in to h em osiderin. Ullm an Introduction Indications Ch ron ic su bdu ral h em atom a CSDH is on e of th e m ost com m on ly t reated n eu rosu rgical disord ers in th e w orld.
Mass e ect. There are some septations within the mixed densit y subdural. On e of th e ben e ts of th e bedside SDH drain age p rocedu re is th e possibilit y to w it n ess rapid n eu rologic im p rovem en t a b Fig.
Min im ize dosing or avoid sedat ion. An t iepilept ic drug prophylaxis sh ould be adm in istered. A small craniotomy was chosen to evacuate the collection. Th e d egree of m id lin e sh ift an d t h ickn ess of su bd u ral blood are u sefu l rad iograp h ic m arke rs to assist clin ical d e cision Chronic Subdural Hem atom as m akin g regard in g op erat ive in te r ve n t ion. This patient was deemed a good candidate for bur hole drainage.
There is mass e ect causing mild shift and left ventricular e acement. Sim ilarly to CT scan n ing. Non con t rast CT u su ally is ad e qu ate to assess t h e age of t h e blood p resen t.
Th e u se of prophylaxis in th e set t ing of m in im ally invasive bedside p rocedu res is left to th e discret ion of th e su rgeon. Sedat ion for bed side procedu res sh ou ld be adm in istered w ith caut ion. MRI m ay be con sid ered for m ore det ailed evalu at ion of m em bran es an d layers if th ere is con cern regard ing th e feasibilit y of cat h eter d rain age.
Sterile skin prep arat ion is perform ed w ith p ovidon e iodin e or ch lorh exidin e. Table 2. Th is st an ds in con t rast to th e d elayed em ergen ce som e often elderly pat ien t s exp erien ce after bur h ole drain age u n der gen eral an esth esia.
Available im aging sh ou ld be st u died carefu lly to determ in e th e ideal en t r y poin t for th e t w ist drill cran iostom y. Bu r h ole p roced u res in th e op erat ing room can be perform ed u n der con scious sedat ion or gen eral an esth esia as p er su rgeon p referen ce or pat ien t toleran ce. Th e target is alm ost alw ays m ore lateral th an th e t ypical in sert ion site for a ven t ricu lostom y or in t racran ial pressure ICP m on itor.
I Cerebral Traum a and Stroke w h en m in im al or n o sedat ing m edicat ion s are used. This case was selected for t wist drill craniostomy. Cran iotom ies t yp ically are p erform ed u n d er gen eral an esth esia. The back of the bed is elevated slightly. The planned bur hole incision sites should fall along the superior lim b of the question m ark. A shoulder roll is placed longitudinally beneath the ipsilateral shoulder.
This will facilitate a m ore extensive opening. The anterior incision is positioned just anterior to coronal suture and the posterior incision. The incision can be further tailored to the location and size of the hematoma. If the CT appearance of the extra-axial uid is both hypodense and homogeneous. Trace out a reverse question m ark—t ype incision over the a ected hem isphere. Use the craniotome to create a small bone ap.
The pericranium is opened w ith Bovie electrocautery and sw ept to either side w ith a periosteal elevator. The bone is elevated—using a blunt surgical tool to dissect any remaining dural attachments to the undersurface of the bone—and set aside in antibiotic solution.
The bone ap will be 4 to 5 cm in diam eter. Self-retaining retractors are placed. Apply bone w ax to the bony edges as necessary. Pearls Bur Holes Right Place a single bur hole at each incision site. The temporalis is incised and is re ected w ith the skin incision. For the craniotomy. A footplate attachment. The membrane should be coagulated w ith bipolar electrocautery and opened sharply w ith a no.
The subdural m em brane often has a brown-green hue. Place epidural tacking stitches circumferentially w ith braided nylon sutures. Line the edges of the craniotomy site w ith thin strips of gelatin sponge soaked in thrombin. If not. Coagulate the dural lea ets w ith bipolar electrocautery to prevent bleeding into the subdural space and to ensure opening of the dura across the full surface area of the bur hole.
A silk suture.
Placing gelatin sponge soaked in thrombin in small pieces or strips along the undersurface of the bone can be helpful in stopping bleeding from membranes in di cult-to-reach areas. Membranes and septations can be broken apart w ith bipolar coagulation. Elevate the syringe. If the uid introduced through one hole does not exit the second hole. The red rubber catheter m ay be guided in any direction where there is presum ed to be hem atom a.
The inner m em brane. It is possible for the catheter to penetrate brain parenchym a or to tear a bridging vein. Monitor the bur hole sites during this process to ensure that there is communication w ithin the subdural space betw een the tw o holes.
Halt irrigation and reassess. If acute hem orrhage is suspected and the uid does not clear with continued irrigation. Craniotomy also facilitates ushing out of m ore organized rests of hem atom a not accessible via bur holes.
The vascularized m embrane can bleed. Consider taking a specimen of membrane as w ell. It is important to control active bleeding. Cover each dural opening w ith a piece of gelatin sponge to prevent further air or blood from entering the subdural space.
The drain can be advanced further if no resistance is encountered. The cavity is irrigated to remove most of the air. In such circum stances. A subgaleal drain m ay be left in place as needed to help prevent a postoperative subgaleal hem atom a or leakage of subgaleal blood into the subdural space.
The dura is closed in an interrupted or running fashion. Gelatin sponge is placed over the cavity prior to replacing the bone ap to prevent air and blood from getting into the subdural space during closure. A sterile dressing is applied. Th e skin aroun d th e in cision s is clean ed of all blood products an d su rgical d ebris. It is som et im es n ecessar y to create a groove w ith a m atch st ick bu r on th e u n dersu rface of th e bon e ap —at th e bur h ole site—in order to avoid kin king of th e drain at it s exit site.
A sim ilar sut ure is placed aroun d th e subgaleal drain. Th e skin is closed w ith staples or w ith nylon su t ures in a ver t ical m at t ress fash ion. Th e in cision site is irrigated w ith an t im icrobial solut ion. For th e sm all cran iotom y: A braided sut ure is placed in a pursest ring fash ion aroun d th e su bdural drain exit site to an ch or th e drain to th e skin an d seal th e sp ace arou n d th e drain.
The ideal entry point is usually sim ilar to a ventriculostomy entry point. Make a small stab incision at the desired insertion site w ith a no. The entry point for the catheter insertion is chosen over a relatively thick part of the SDH that is safely accessible.
The tw ist drill can be started in the usual perpendicular angle. Usually this means tilting the drill tip posteriorly in order to angle the hole posteriorly. Since the catheter is usually in place for only 12 to 48 hours. A com plex extern al ven t ricular drain system is n ot required sin ce ICP w ill n ot be m easured. Th e skin is prepared in a sterile fash ion. Th e drain is placed to gravit y drain age. Skin st ap les or su t u res are rem oved after 1 to 2 w eeks.
Th e drain age collect ion bag w ill en d up at or n ear oor level as th e last of th e SDH is drain ed. Pat ien t s are m ain t ain ed relat ively at in bed 0—20 degrees u n t il th e drain s are rem oved.
Pat ien t s seem to bet ter tolerate slow drain age of th e SDH. Ch anges in p osit ion m ay act u ally facilit ate drain age of th e SDH. Th e cath eter-an ch oring sut u re is cu t free from th e cath eter an d th e cath eter is rem oved.
A suture is placed in position to serve as a closing suture for after the catheter is removed. Th e drain sh ould be discon t in ued after 2 to 4 days. Th e pat ien t can be log rolled side-tosid e. Sin ce th e cath eter is usu ally in p lace for on ly 12 to 48 h ou rs.
Th e h ead of th e bed is kept at to prom ote gravit y drain age of th e SDH. Th e previously placed closing sut u re is t ied t igh tly to com plete th e closure of th e exit site. Place th is st itch prior to th e an ch oring st itch so you can m ove th e cath eter aside an d p osit ion th e st itch w h ere th e cath eter w ill be on ce it rela xes back in to posit ion.
Chronic Subdural Hem atom as h ou rly n eu rologic ch ecks as long as th e d rain is in p lace. In rare cases.
Dress th e site w ith a dr y gau ze dressing an d a h ead w rap. Th e pat ien t can be allow ed to raise th e h ead of th e bed to 10 to 15 degrees for eat ing. Drains are rem oved in a sterile fashion. Th is gives th e n u rses a clear object ive goal in order to m ake safe an d app rop riate adju st m en ts to th e drain level.
W h en th e SDH drain age h as ceased or slow ed sign i can tly. Th e lat ter provides a secure dressing w ith w h ich to an ch or th e extern al drain age t ubing. It w ill becom e n ecessar y to low er th e drain gradually over several m in utes to several h ou rs as th e p ressu re in th e su bdu ral sp ace decreases Fig.
Usually th e rem ain ing subdural u id w ill resolve sp on t an eou sly over t im e w eeks to m on th s. For t w ist drill cran iostom ies.
The patient also has a smaller subacute right parietal subdural collection which was treated conservatively. Con sider a repeat CT scan about 3 days after drain rem oval to evaluate for reaccum ulat ion. Barring a ch ange in n eu rologic st at us.
Dexam eth ason e. I Cerebral Traum a and Stroke b a Fig. Note the approximately mL chronic subdural hematoma uid already in the drip chamber. There is pneumocephalus and improvement in m ass e ect. Prim ar y t reat m en t w ith an oral an t i brin olyt ic. There is a Jackson-Prat t drain in the subdural space and mild pneumocephalus with improvement in mass e ect.
Maeda M. Special Considerations Su bdu ral reaccu m u lat ion is a kn ow n risk of op erat ive t reatm en t. Neurol Med Ch ir The tip of the subdural catheter can be seen in the subdural space arrow. Mori K. W h ile the focus of th is chapter does n ot in clude the m edical t reat m ent of subacute an d chron ic subdural h em atom as.
Nat ion al Neu rosu rgical Procedu ral St at ist ics. Rolling Meadow s. Am erican Associat ion of Neu rological Su rgeon s. Reop erat ion m ay be n ecessar y.
A secon d reaccu m u lat ion m ay requ ire su bd u ral—periton eal sh u n t ing w ith ou t a valve. Th e rat ion ale for th e u se of cort icosteroids is based on the ant iangiogenic propert ies an d inh ibit ion of the in am m ator y react ion. Su rgical t reat m en t of ch ron ic su bdu ral h em atom a in con secu t ive cases: Th is m in im ally invasive ap p roach h as in d icat ion s sim ilar to t h e t w ist d r ill cran iotostom y.
References Fig. Ram ach an d ran R.
Inam ura T. Non su rgical t reat m en t of ch ron ic subdu ral h em atom a w ith t ran exam ic acid. Fukui M. Use of drains versus no drains after bur-hole evacuat ion of chronic subdural hem atom a: Toyooka T.
Rato R. Suzuki SO. Su n TF. J Neurosurg Rasm u sse n IA. Tu rh im S. Santarius T. Braxton E. Kagaw a M. Ch ron ic calci ed subdural h em atom a: Case repor t an d review of the literat ure. Shono T. Alu clu U. Ret rospect ive st at ist ical an alysis of clinical factors of recurren ce in ch ron ic subdural h em atom a: Neuroch irugia Ast ur Takah ash i H. Takayam a M.
Non -su rgical p rim ar y t reat m en t of ch ron ic subdural h em atom a: Kageyam a H. Man agem en t of in t racran ial h em orrh age associated w ith an t icoagulan t th erapy. Novais G. Vascular endothelial grow th factor in chronic subdural haem atom as.
Ried er. Grossw asser I. Avrah am i E. Kirkpatrick PJ. Hobbs J. St at ist ical an alysis of chron ic subdu ral h em atom a in adu lt cases. Bilici A. Tsu zu ki N. Qu igley MR. Ikezaki K. Fron tera JA. Hash izu m e K. Lancet Ganesan D.
Iw aki T. Hegd e T. Gu zek E. Coh n DF. Cast illa-Diez JM.
Atlas of emergency neurosurgery
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English View all editions and formats Rating: Subjects Nervous system -- Surgery -- Atlases.Pay particular at tention to any open air cells at the temporal bone m argins. Reconstructive surgery a. Tim m o ns. Raj K. Share This eBook:. S2—62 Half-st rength hydrogen p eroxide or n orm al salin e-soaked cot ton balls m ay be u sed to t am pon ade gen eralized oozing as w ell. Man agem en t of CSDH t yp ically involves su rgical evacu at ion of th e clot an d placem en t of post surgical drains to preven t reaccum ulation of blood in th e subdural space.
References 1. Th e drain age collect ion bag w ill en d up at or n ear oor level as th e last of th e SDH is drain ed.
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